Economic Burden Associated With Untreated Mental Illness in Indiana

Key Points Question How much does untreated mental illness cost society? Findings This cross-sectional study of approximately 429 407 Indiana residents found that in 2019, untreated mental illness was associated with $4.2 billion in annual societal costs, consisting of $3.3 billion in indirect costs, $708.5 million in direct health care costs, and $185.4 million in nonhealth care costs. Meaning These findings suggest that the financial toll of untreated mental illness at the societal level is substantial and warrants investments in mental health care access, treatments, and workforce.

This supplemental material has been provided by the authors to give readers additional information about their work.

eMethods 1: Definition of Serious Mental Illness (SMI) and other mental illnesses (oMI)
There are multiple existing definitions of mental illnesses, including SMI. 1 For instance, the National Institute of Mental Health defines SMI as "any mental, behavioral, or emotional disorder resulting in serious functional impairment." 2 The National Committee on Quality Assurance (NCQA) defines individuals with SMI as those who meet at least one of the following criteria within the measurement period: (1) at least one acute inpatient claim/encounter with any diagnosis of schizophrenia, bipolar I disorder, or major depression, OR; (2) at least two visits in an outpatient, intensive outpatient (IOP), partial hospitalization (PH), emergency department (ED), or nonacute inpatient setting, on different dates of service, any diagnosis of schizophrenia, OR; (3) at least two visits in an outpatient, intensive outpatient, partial hospitalization, emergency department, or nonacute inpatient setting on different dates of service with a diagnosis of bipolar I disorder. 3Although we acknowledge differences in existing definitions of mental illnesses, 1 including SMI, for the purposes of the current analysis we defined SMI conditions consistent with how it is defined by the Indiana FSSA (see eTable 1).
© 2023 Taylor HL et al.JAMA Health Forum.   4 eMethods 2: Methodological approach for estimating direct non-healthcare and indirect costs Our framework for estimating direct non-healthcare and indirect costs consisted of a series of equations for each outcome we identified.First, because not all individuals with SMI or oMI experience an outcome due to their illness, we had to estimate the excess risk of an individual experiencing the outcome attributable to their SMI or oMI.This was calculated by subtracting the risk of the outcome among the general population from the risk of the outcome among those with SMI or oMI.Next, the excess risk was multiplied by the total population in Indiana with SMI or oMI, the expected untreated or undertreated proportion of the SMI or oMI population, 5,6 and the annual cost of each outcome per person.We assumed that the untreated proportion of those with SMI or oMI in each outcome is proportional to the untreated proportion of SMI or oMI in the general population of Indiana.Each direct non-healthcare and indirect outcome was estimated using the steps described above.An example as to how we walked through each calculation is provided in Supplemental Material eMethods3.
To estimate costs attributable to premature mortality (all-cause mortality and suicide), an additional method was used -the human capital method. 7The human capital method estimates the economic value of an average individual's future earnings had they not missed work due to death or illness. 7Thus, we estimated the gross income lost among those that died prematurely before the retirement age of 65.Specifically, we used the Centers for Disease Control and Prevention WONDER dataset 8 to determine the number of individuals in Indiana who died due to any causes (other than intentional harm) before the age of 65 in 2019.For each death, we tabulated the number of working years lost (between the ages of 18 and 64) and multiplied it by the excess number of individuals with SMI or oMI and the average 2019 annual wage in Indiana.
For deaths due to intentional harm or suicide (ICD-10-Clinical Modification Codes X71-X83), we tabulated the total number of working years lost and multiplied this number by the excess number of individuals with SMI or oMI and average 2019 annual wage in Indiana. 9nally, specific details and parameters used for the estimation of each direct nonhealthcare and indirect outcome, including premature all-cause mortality and suicide, can be found in Supplemental Material eMethods4, eTable3.Our framework for estimating direct non-  For example, to estimate jail incarceration costs attributable to untreated SMI, we began with the 2019 adult jail population (n=20,880), 10 the proportion of Indiana's jail population with SMI (26%), 11 the population in Indiana with SMI (n=296,000), 5 and the general adult population in Indiana without SMI (n=4,733,000). 5 These data allowed us to determine the risk of jail incarceration among the general Indiana adult population (0.003) and the risk of jail incarceration among adults with SMI (0.018).Then we subtracted the risk of jail incarceration among the general population from the risk of jail incarceration among those with SMI to calculate the excess risk of jail incarceration attributable to SMI (0.015).The excess risk (0.015) was then multiplied by the adult population in Indiana with SMI (n=296,000), the proportion of adults in Indiana with untreated SMI (0.525), the average length of stay per Indiana jail resident (26 days), 12 and the average daily cost of incarceration per jail resident in Indiana ($54.00), 13 to estimate the total costs of jail incarceration attributable to adults with untreated SMI to be $3,291,954.63.who experience the outcome, the proportion of this population assumed to be undertreated or untreated, 5,6 and the cost of each outcome per person within a 12-month timeframe.Details and sources related to each outcome estimation are described below and listed in eTable 3.

Direct non-healthcare costs
Criminal Justice System -Costs incurred within jails, prisons, and juvenile detention centers were estimated based on the general population incarcerated, 10,14 the excess number of individuals with SMI and oMI in each of these correctional facilities, 11,15,16 the average length of stay per correctional facility, 12,17,18 and the annual cost per day per resident within each correctional facility. 13,19,20The excess criminal justice system costs attributable to untreated mental illness were calculated by multiplying the annual cost of incarceration, the excess number of individuals incarcerated with SMI and MI, and the expected proportion who are untreated based on NSDUH or NSCH data. 5,6meless services -Costs associated with homeless shelters were estimated based on the general homeless population, 21 the prevalence of SMI and oMI residing in homeless shelters, 22,23 the average length of stay in a homeless shelter, 24 and the costs per day per individual in a homeless shelter. 25,26Costs were separately calculated for the proportion of the population who are chronically homeless (have at least one disability and on average are homeless for at least one year). 23The excess homeless service costs attributable to untreated mental illness were calculated by multiplying the annual cost of © 2023 Taylor HL et al.JAMA Health Forum.
an individual residing in a homeless shelter, the excess number of homeless individuals with SMI and MI, and the expected proportion who are untreated based on NSDUH or NSCH data. 5,6direct Costs Unemployment -Costs associated with unemployment were estimated based on the total labor force in Indiana, 27 the proportion unemployed in Indiana (ages 18-64), 27 the excess number of individuals unemployed with SMI or oMI, 28 and the average mean wage in Indiana. 9The excess unemployment costs attributable to untreated mental illness were calculated by multiplying the annual lost wages due to unemployment, the excess number of individuals unemployed with SMI and MI, and the expected proportion who are untreated based on NSDUH. 5rkplace productivity losses -Costs for absenteeism were based on the number of individuals with full-time employment and SMI or MI, 27,29 the mean hourly wage for Indiana, 9 and the average excess total hours absent per year attributable to SMI & MI conditions. 30,31Estimates for presenteeism were based on the number of individuals with full-time employment and SMI or MI, 27,29 the mean hourly wage for Indiana, 9 and the average excess total hours of lost productivity in a year attributable to SMI & MI conditions. 30,31The excess workplace productivity losses attributable to untreated mental illness were calculated by multiplying the annual cost of excess hours of absenteeism and presenteeism per individual employed with SMI or MI and the expected proportion who are untreated based on NSDUH. 5emature mortality -All-cause mortality -Costs associated with all-cause mortality were estimated using the human capital method among individuals who died before the © 2023 Taylor HL et al.JAMA Health Forum.age of 65 for any cause other than intentional harm.All-cause mortality in Indiana was obtained from the Centers for Disease Control and Prevention WONDER dataset for the year of 2019.Costs associated with all-cause mortality were based on the average mortality rate for the general population, 32 the risk of premature death among those with SMI or oMI, 33 and the average wage of working adults in Indiana. 9We calculated the total years lost to premature mortality from age 18 to 65 for each individual identified.
Excess costs associated with all-cause premature mortality attributable to untreated mental illness were calculated by multiplying the total years of life lost among the excess number of individuals with SMI or MI who died prematurely and the average annual wage in Indiana.
Premature mortality -Suicide -Costs associated with suicide were estimated using the human capital method among individuals (ages 5-64) whose underlying cause of death in 2019 was suicide (deaths from intentional harm).This information was obtained from the Centers for Disease Control and Prevention WONDER dataset. 34We attributed all suicide deaths to untreated mental illness and estimated the total years lost to suicide from age 18 to 65 for each individual identified.Total years lost for the entire population was then multiplied by the average annual wage in Indiana. 9regivers' productivity loss -Cost estimates were based the number of caregivers in Indiana, 35 the proportion of individuals with SMI or oMI who require a caregiver, 36,37 the mean hourly wage, 9 and the annual excess hours caregivers spend devoting time to family with an SMI or oMI. 36The excess caregiver productivity losses attributable to untreated who require family caregiving, the annual cost of excess hours lost due to caregiving, and the expected proportion who are untreated based on NSDUH. 59][40] The excess caregiver productivity losses attributable to untreated mental illness were calculated by multiplying the number of individuals with SMI and MI who require family caregiving, the caregivers' average annual excess healthcare costs, and the expected proportion who are untreated based on NSDUH. 5imary education funding losses -The excess primary education funding losses attributable to untreated mental illness were calculated by multiplying the number of school-age children who experience any MI, 6 excess number of days children with SMI and MI are absent from school due to their illness, 41 Indiana's funding contribution to primary education per student per day, 42  We assumed that those who received treatment for SMI or oMI experienced sequelae of the illness for some period prior to the diagnosis, procedures, or medication. 45,46Therefore, the healthcare services were tabulated.Since our focus was on all excess costs beyond mental health treatment, any claims with a SMI or oMI procedure, medication, or diagnosis were excluded from the total costs.Among enrollees meeting the definition of having untreated SMI or oMI, we subtracted the total annual healthcare costs in year 2 from year 1, and likewise for the matched comparison group.We then took the difference in costs from the untreated SMI or oMI group and the matched comparison group to estimate the cost of untreated disease.To extrapolate costs to privately insured individuals, we multiplied the cost of unmanaged/untreated disease among the Medicaid population by a conversion factor of 1.7 (95% CI: 1.1 to 2.1), which has been previously used to convert Medicaid costs of MI to private insurance. 47,48Finally, to capture the total excess direct healthcare costs attributable to untreated and undertreated SMI or oMI, we multiplied the excess cost of SMI or oMI by the proportion of the statewide population expected to have untreated SMI or oMI.

eMethods 4 .
Details on Direct Non-Healthcare Cost Estimations and Indirect Cost Estimations eTable 3. Parameter and Assumption Details on Direct Nonhealthcare Cost Estimations and Indirect Cost Estimations eMethods 5. Methodological Approach for Estimating Direct Healthcare Costs eReferences.
healthcare and indirect costs, including model inputs and specific sources, can be found at https://hdl.handle.net/1805/34678.© 2023 Taylor HL et al.JAMA Health Forum.

eMethods 3 :
Example calculations to estimate jail incarceration costs attributable to untreated serious mental illness

eMethods 4 :
Details on direct non-healthcare cost estimations and indirect cost estimations All estimates are based on 2019 Indiana specific parameters derived from the literature and government sources.Excess costs for each outcome listed below were calculated by multiplying the excess number of individuals with serious mental illness (SMI) or other mental illness (oMI) mental illness were calculated by multiplying the number of individuals with SMI and MI © 2023 Taylor HL et al.JAMA Health Forum.
difference in costs post-treatment versus pre-treatment represent costs attributable to untreated or undertreated SMI or oMI.Health service costs accrued in the year prior to SMI or oMI treatment, and costs accrued in the first year of treatment were totaled.Total health care expenditures, including inpatient care, outpatient care, emergency departments, pharmacy costs, and other © 2023 Taylor HL et al.JAMA Health Forum.

eMethods 1 .
Definition of Serious Mental Illness (SMI) and Other Mental Illnesses (oMI) eTable 1.International Classification of Disease (ICD-10-CM) Diagnoses Codes for Serious Mental Illness and Serious Emotional Disturbance Used by the State of Indiana eTable 2. Categories of International Classification of Disease (ICD-10-CM) Diagnoses Representing Mental Illnesses Included In Analyses eMethods 2. Methodological Approach for Estimating Direct Non-Healthcare and Indirect Costs eMethods 3. Example Calculations to Estimate Jail Incarceration Costs Attributable to Untreated Serious Mental Illness 4eTable 2 displays Breslau et al's groupings.
© 2023 Taylor HL et al.JAMA Health Forum.
44d the expected proportion who are untreated based on NSCH.6eTable 3. Parameter and Assumption Details on direct non-healthcare cost estimations and indirect cost estimations Methodological approach for estimating direct healthcare costs To estimate direct healthcare costs of untreated SMI and oMI, we used a retrospective matched cohort design using Indiana Medicaid claims.First, we created a cohort of enrollees (age 5 years and older) with at least 24 months of continuous enrollment spanning calendar years 2018 and 2019.Next, we identified which of those enrollees had a SMI or oMI using a combination of primary diagnosis codes, mental health-related procedure codes as defined by the Indiana Health Coverage Program Fee Schedule,43or the presence of pharmaceutical medications commonly prescribed to treat SMI or oMI according to the National Committee on Quality Assurance HEDIS® 2019 Medication List Directory of National Drug Codes.44Next,we identified enrollees who met our definition of SMI or oMI in their second 12 months of enrollment but not during their first 12 months.Thus, if the enrollee was receiving treatment or services in their first year of enrollment, as indicated by claims with primary diagnosis codes, procedure codes, or medications associated with SMI or oMI, they were not included.Next, we matched enrollees (who met our inclusion criteria) by sex, age, race, and county of residence to individuals with no primary diagnosis codes, procedure codes, or medications associated with SMI or oMI during the entire 24-month. A individual who reached age 64 before December 31, 2019, was also excluded since Medicare incurred costs are not observable in these data.
a -Serious mental illness b -other mental illness (excluding serious mental illness) c -any mental illness d -point estimate with no confidence interval or range data available eMethods 5: